Provider Demographics
NPI:1720524762
Name:BONITA STREETMAN, LLC
Entity Type:Organization
Organization Name:BONITA STREETMAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STREETMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCSW, LCAC
Authorized Official - Phone:317-446-4125
Mailing Address - Street 1:1445 DOMINION DR
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-1872
Mailing Address - Country:US
Mailing Address - Phone:317-446-4125
Mailing Address - Fax:
Practice Address - Street 1:2633 E 136TH ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1855
Practice Address - Country:US
Practice Address - Phone:317-446-4125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-14
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002619A251S00000X
IN87000793A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health